TO THE EDITOR: Compulsive skin picking (CSP) is a symptom rarely observed in obsessive-compulsive disorder, body dysmorphic disorder, delusional syndromes, illicit substance use, and some genetic syndromes. The clinical syndrome was classified in DSM-IV as an impulse control disorder, not otherwise specified, and possibly related to other body-focused repetitive behaviors.1 Following the recommendation of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group,2 the syndrome will be included in DSM-5 as excoriation (skin picking) disorder,3 with its own set of criteria concerning recurrence, associated distress or impairment, and exclusion of other causes. Agomelatine is a novel antidepressant combining 5-HT2C receptor antagonisms with melatonergic agonisms (MT1 and MT2 receptors).4 This report describes a patient with a CSP episode who remitted after initial selective serotonin reuptake inhibitor (SSRI) treatment augmentation and a transition to agomelatine.

Ms. A, age 20, has mild mental retardation (IQ in 50 to 70 range) and autistic features and presents with CSP after a stressful event (emergency dental care). There are no pathological findings during prenatal screening. Ms. A’s mother was age 38 at the time of the patient’s birth, and delivered via caesarean section. At age 3, after a hepatitis B vaccination, Ms. A developed febrile seizures and was hospitalized. Presently she requires assistance with everyday tasks and her family cares for her. Ms. A typically avoids eye contact, has a reduced attention span, trouble concentrating on a task, and difficulty orientating in space. Decreased sensitivity to pain also was noted. Ms. A required no pharmacological treatment before she developed CSP. Before hospitalization, routine blood tests were normal, dermatologic evaluation was clear, and symptomatic treatment with anti-allergic agents did not provide relief. No other health problems are evident.

Upon admission, clinical examination confirms autistic features but reveals no psychotic symptomatology. Ms. A has no visual or tactile hallucinations, although intense anxiety is evident. No other compulsions are present or were reported in the past. Ms. A is not a suitable candidate for psychotherapy because of her low IQ and intense stress level. Because research favorably describes SSRI use in skin picking,5 initial treatment consisted of sertraline titrated to 150 mg/d. Quetiapine extended release, titrated to 200 mg/d, was added to facilitate behavioral self-control,6 which was lacking because of Ms. A’s autistic features and the stress of hospitalization.

After having no effect for 25 days, 25 mg/d of agomelatine was added for augmentation. Skin picking lessened, and the patient regained pre-incident stability. Sertraline and quetiapine are discontinued without any symptom exacerbation, and Ms. A is discharged a week later. She is in remission at her 1-month follow-up and agomelatine treatment is stopped. Ms. A remains asymptomatic at her 3- and 6-month follow-ups. Diagnosis is oriented towards a genetic syndrome (such as 22q13.3 deletion syndrome)7 with skin picking rising as a compulsive response to intense anxiety. Ms. A’s clinical response is attributed to the melatonergic action of agomelatine.

DISCLOSURES: The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. This manuscript was entirely funded by the authors, and no pharmaceutical companies were informed of or were involved in the paper. All authors have contributed to this case report with equal efforts.